Current Treatment of Mycetoma

Abstract

The purpose of this review is to update the status of treatment of actinomycetoma and eumycetoma. Specific information is presented to describe the best medical management for uncomplicated and complicated actinomycetic and fungal mycetomas. Localized actinomycetoma that involves the skin without affecting underlying organs is treated with trimethoprim/sulfamethoxazole for 3 to 12 months. In extensive infections with bone or deep organ involvement and in those with no therapeutic response, amikacin can be added. Duration of treatment varies from 5 to 20 weeks and will depend on clinical response, development of adverse effects, and patient comorbidities. Other antibiotics including diaminodiphenylsulfone (DDS), amoxicillin/clavulanic acid, rifampicin, minocycline, moxifloxacin, imipenem, meropenem, and linezolid may be employed in different combinations in selected cases. If available, an antibiogram should guide antimicrobial therapy. Eumycetoma treatment includes itraconazole, voriconazole, posaconazole, and terbinafine. Surgery is indicated depending on disease extension, antifungal clinical response, and localization. Trimethoprim/sulfamethoxazole (TMP/SMZ) is the drug of choice for actynomicetoma but amikacin can be added in complicated cases. When aminoglycosides are contraindicated, other antimicrobials can be employed; surgery is seldom indicated. In eumycetoma, itraconazole is currently the first-line therapy, and terbinafine can be added in complicated cases. Other azoles are unavailable or expensive. Experimental in vitro and in vivo studies with different antimicrobials are currently underway for actinomycetoma. In eumycetoma, a comparative double-blind randomized study with itraconazole and fosravuconazole along with surgical treatment is being carried out at the Mycetoma Research Center in Khartoum, Sudan. Clinical awareness about mycetoma among physicians will allow a prompt diagnosis and treatment.